1509 S.W. Sunset Blvd., Suite 1-B
Portland, Oregon 97239
Phone: 503.819.8205
E-mail: bff@bff.org / Web: www.bff.org

The Blanche Fischer Foundation is a private, nonprofit charitable institution founded in 1981 for the purpose of assisting persons who have a disability that challenges them physically and who have financial need. There are three criteria for consideration for a grant from the foundation:

You must be an Oregon resident;
You must have a disability of a physical nature; and
You must demonstrate financial need.

Applicants may apply for financial aid for education, special equipment or for such other purposes as the foundation finds appropriate.

Please Note

• PRINT OUT this application. If it comes out poorly, check out one of the other versions available elsewhere on this site (How to Apply) or write, e-mail (bff@bff.org) or call us with your name and address and we will mail you one.
• The application must be filled out completely and signed by the applicant or applicant's legal guardian.
• Medical or other satisfactory verification of disability (letter from physician or other health care professional) is required.
• We do not accept faxed applications. You must MAIL the original, along with documentation, to the foundation. This is necessary for the foundation to comply with state and federal requirements.

GRANT APPLICATION

Name of applicant (person for whom assistance is requested):

Address:

City, State, ZIP:

Telephone/TTY (including area code):

E-mail:

I. Information About Your Disability

Briefly describe your disability:
How long has this condition existed?
Is your condition permanent? (Yes / No)
If no, expected duration:
How does this affect your daily life and independence?
For what purpose are you requesting funding?
How much does it cost?
How much do you need the Blanche Fischer Foundation to contribute?
How will this grant improve your quality of life?
Name and address of vendor or supplier (attach copy of price quote or order information):

Yes, it's attached!
Have you applied for grants from any other source(s)? (Yes / No)

From whom?

How much?
Have any been approved? (Yes / No)

By whom?

In what amount(s)?
Have you ever received vocational training? (Yes / No)
From whom (state agency, federal, private organization)?

When?

Did this training result in employment? (Yes / No)
Attach a letter or report from your doctor or other licensed health care professional (social worker, case manager, etc.) verifying your disability.

Yes, it's attached!

II. Application for Benefit

NOTE: ALL household members must be considered in replying to income-related questions.

General Information

Applicant's birth date
If a minor, name of parent(s) or guardian(s)
Age of each child in household
Number and relationship (parent, spouse, caregiver, etc.) of adults in household
Number of wage earners in household
Occupation(s)
Employer(s) name(s)
Work phone (if applicable)

Income and Expenses

A. Monthly Income: Salary and Wages

Earner	Gross Monthly Salary	Monthly Take-Home Pay
Primary wage earner	$	$
Secondary wage earner	$	$

B. Monthly Income: Other

Income Source	Amount Received Monthly
Social Security	$
Child support	$
Food stamps / Oregon Trail	$
Other (describe):	$

C. Monthly Expenses

Category	Monthly Payment	Balance Owed
Food	$
Clothing	$
Utilities	$
Health care (medical, dental, vision, prescriptions, etc.)	$	$
Insurance	$
Payments (credit cards, car payments, loans, etc.)	$	$
Other (describe):	$	$
	$	$

D. Medical Insurance

What kind of medical insurance, if any, do you have? Circle or mark an "X" over all applicable responses:

Insurance Type	Yes	No
None	Yes
Private Insurance	Yes	No
Medicare	Yes	No
Oregon Health Plan	Yes	No
Other (describe):	Yes	No

E. Assets

Circle or mark an "X" over the applicable response, and fill in blanks as applicable:

Do you rent or own your residence?	Rent	Own
What is your monthly payment?	$
Do you own any other real property?	Yes	No
If yes, please describe:
Automobile 1 (value)	$
Make and year:
Automobile 2 (value)	$
Make and year:
Amount of cash in bank accounts and any stocks, bonds or securities, including retirement plans and living trusts (value)	$
Description:

III. Other Information You May Wish Us to Consider (attach letter, if desired):

All grants made assume the accuracy of this application. I understand that if a grant is awarded, payment can be made only to the supplier of goods or services. I further understand that all decisions as to eligibility and grants are made at the sole discretion of the Blanche Fischer Foundation and that its decisions are final.

I understand that all grants awarded by the Blanche Fischer Foundation must be reported on the foundation's federal and state tax returns, and as such, grantees' names, addresses and grant amounts are a matter of public record.

Signature(s)

Applicant:

Parent/Guardian (please indicate which):

Your response to the following question will not influence in any way the outcome of this grant application: Would you like us to send you a Voter Registration Card, along with the names of your state senator, representative and U.S. Congressional representative? Yes / No

Before mailing this application . . .

Are all sections complete?
Have you attached documentation from a medical or other professional verifying disability?
Have you attached a copy of your vendor’s price quote?

Mail the completed and signed application, along with all supporting documentation, to:

Blanche Fischer Foundation
1509 S.W. Sunset Blvd., Suite 1-B
Portland, Oregon 97239

Return to How to Apply